Differential diagnosis in early childhood

Transcript

• 00:00Good afternoon, everyone, and welcome
• 00:02to Grand Rounds.
• 00:04I've already muted. I'm muted.
• 00:05Thanks. Sam was just trying
• 00:06to adjust the comfort level
• 00:08in the room for anyone
• 00:08that's, a little bit too
• 00:10cozy at the moment. Thank
• 00:11you, Sam.
• 00:12So today is our last
• 00:14Grand Rounds of this year.
• 00:15I'd like to start by
• 00:16wishing you all a very
• 00:17happy holiday season and happy
• 00:19new year. We'll be getting
• 00:20started on January seventh with
• 00:22doctor Linda Mays with her,
• 00:24annual address to kick off
• 00:26Grand Rounds for next year.
• 00:27But today, we're ending on
• 00:29a high, and we're delighted
• 00:31that doctor Kasia Habarska has
• 00:33decided to give grand rounds
• 00:34today. All of you know,
• 00:36doctor Habarska
• 00:38and her fantastic work trying
• 00:39to identify,
• 00:40early diagnostic farm,
• 00:42markers and novel treatment targets
• 00:44for autism spectrum disorders.
• 00:47Doctor Hovashka is the, Emily
• 00:48Fraser Beatty professor of child
• 00:50psychiatry, pediatrics, and statistics,
• 00:53and is the director of
• 00:54the NIH funded, Center for
• 00:56Excellence, for autism spectrum disorders
• 00:58here at the Yale Child
• 00:59Study Center. And so, please
• 01:01join me in welcoming Kasia
• 01:02and thanking her for giving
• 01:03the last grand rounds of
• 01:04twenty twenty four.
• 01:10Thank you so much. You
• 01:11know, it's always,
• 01:13it's always fun to give
• 01:14talks,
• 01:15but it's always the greatest
• 01:16pleasure to do it at
• 01:17home. So, I'm really grateful
• 01:19for this opportunity, and thank
• 01:20you for for inviting me.
• 01:22And thanks for everyone being
• 01:24here. I know this is
• 01:25the busiest time of
• 01:27the year, and I know,
• 01:29many of us are still
• 01:30in connects
• 01:31right now.
• 01:33But I really appreciate everyone
• 01:34online and here in the
• 01:35room for being here.
• 01:38So,
• 01:39the reason behind this talk
• 01:41is behind this topic is
• 01:42that,
• 01:44Kelly,
• 01:45a group of amazing clinicians
• 01:47in in our lab, in
• 01:48our clinic, Kelly,
• 01:51Paula, Mariana Torres, and Chelsea
• 01:53Morgan.
• 01:54And I have been, having
• 01:56discussions
• 01:56about,
• 01:57differential diagnosis in babies.
• 02:00Right?
• 02:02Spurred by the fact can
• 02:04you hear me?
• 02:05Spurred? No. I I think
• 02:06I'm I think I'm using
• 02:08it. Can you hear me?
• 02:08Yes.
• 02:10Okay.
• 02:11Spurred by the fact that,
• 02:12in, in the past twenty
• 02:14five years, we've been seeing
• 02:15a lot of toddlers in,
• 02:17our clinics and through research
• 02:18programs.
• 02:20And, we are always struck
• 02:21by the complexity
• 02:22of the clinical presentation
• 02:25and,
• 02:26and difficulty sometimes in considering,
• 02:28what the primary diagnosis might
• 02:30be and, difficulties in making
• 02:32predictions,
• 02:34about outcomes,
• 02:35of these kids. So today,
• 02:37I would like to invite
• 02:38you to kind of walk
• 02:39with me through what we
• 02:41know, what we don't know,
• 02:42and think about,
• 02:44where we would like to
• 02:45be in ten years, from
• 02:46now in terms of,
• 02:48creating new
• 02:50or better diagnostic,
• 02:52approaches to early diagnosis. We're
• 02:54gonna talk about a little
• 02:55bit about the,
• 02:58concept of differentiation.
• 03:00We'll talk about,
• 03:02you know, what what do
• 03:03we know about early manifestation
• 03:05of some of the,
• 03:06complex neurodevelopmental
• 03:08conditions we deal with, including
• 03:10autism and ADHD,
• 03:13some clinical implications
• 03:14about from what we know
• 03:16or we don't know,
• 03:18and, perhaps about some new
• 03:20directions or or or glimpses
• 03:22of new directions,
• 03:24that might, might give us
• 03:25a little bit more a
• 03:26better sense or different sense
• 03:28of of,
• 03:29of, differential diagnosis.
• 03:32So, I want you to
• 03:33sit back and imagine
• 03:35that in a galaxy far,
• 03:36far away,
• 03:38little brains,
• 03:40read the diagnostic instruments.
• 03:42And,
• 03:44accordingly they develop accordingly to
• 03:46what they read and, develop
• 03:48very nicely separated
• 03:51phenotypes.
• 03:52They are very clearly,
• 03:54delineated
• 03:55and, very clearly,
• 03:57defined.
• 04:01In our galaxy, however,
• 04:03in our Milky Way galaxy,
• 04:05things are a little different.
• 04:07At at the least, we
• 04:08see significant overlaps between,
• 04:11children who are presenting with
• 04:14neurodevelopmental
• 04:15conditions being autism, global delays,
• 04:18language,
• 04:18disorders, or or motor stereotypies.
• 04:22Actually, this may look,
• 04:25complicated.
• 04:27There's a delay in the
• 04:28display.
• 04:29Is that okay?
• 04:32There's a bit of a
• 04:32delay in the display of
• 04:33the slides.
• 04:37Okay. So I'll just now
• 04:38that I know it's there,
• 04:40I will be mindful about
• 04:41that. Sorry about this. So
• 04:42so this is pretty much
• 04:43what we see in our
• 04:44clinics. It's much more likely
• 04:46to see we're much more
• 04:47likely to see in the
• 04:48in our clinics
• 04:49considerable overlap
• 04:51between, in symptom expression,
• 04:53in children representing for differential,
• 04:56diagnosis.
• 04:58If that was really the
• 04:59case, this would be actually
• 05:00very nice.
• 05:01In reality, what we are
• 05:02seeing is something like that.
• 05:04It's something like that. The
• 05:06children who are referred to
• 05:07us for differential diagnosis,
• 05:09one, two, three,
• 05:11four,
• 05:12five,
• 05:13six, seven, eight, nine, ten.
• 05:16We have a delay.
• 05:18Can we?
• 05:22Can we do something about
• 05:23it?
• 05:24Do you want to I
• 05:26think everything we need to
• 05:26do is stop share and
• 05:27reshare.
• 05:28Uh-huh.
• 07:30Clinics is something like that.
• 07:32We see some children who
• 07:33are presenting with a more
• 07:34clear clinical pictures,
• 07:37that we can see here
• 07:38clustering the same color on
• 07:39the periphery.
• 07:40But in reality, we also
• 07:42see a lot of kids
• 07:43who are actually presenting in
• 07:44multiplicity of symptoms
• 07:46coming from a variety of
• 07:47different, syndromes. And our
• 07:50job here is to make
• 07:52a,
• 07:53clinically,
• 07:54informed, relevant, and helpful to
• 07:57the family,
• 07:58differentiation.
• 08:04Sam.
• 08:06Hi, Sam.
• 08:14Ten seconds.
• 08:16I got slides on the
• 08:17computer here if you want.
• 08:18Do whatever. Yeah.
• 08:21Yeah.
• 08:22Do whatever. So how many
• 08:24people are, here working with,
• 08:27faced with the issue of
• 08:28differential diagnosis on a daily
• 08:30basis?
• 08:33Lots of clinicians.
• 08:34So it's relevant.
• 08:36You know, I typically do
• 08:37research. I I don't see
• 08:39patients these days a lot,
• 08:41but it's also tremendously important
• 08:42from us from the, research
• 08:44standpoint because after all, after
• 08:46it's all said and done,
• 08:48we do,
• 08:49most cases,
• 08:50come back to the question,
• 08:52what is the group? What
• 08:53is the differential? Right? How
• 08:55can we come how can
• 08:56we differentiate our complex phenotypes
• 08:59in order to, at the
• 09:00end, end up with phenotypes
• 09:01which are separated enough so
• 09:03we can actually see something
• 09:05important or or new, in
• 09:07terms of our,
• 09:09outcome variables.
• 09:23Oh,
• 09:24that's awesome.
• 09:26You think? Oh, yeah. She
• 09:28did that.
• 09:29She did that thing as
• 09:30well.
• 09:41I think everything is in
• 09:42holiday mode already. So
• 09:45Just
• 09:47be chill.
• 09:48Be chill.
• 09:49Go down. Down. Down.
• 09:51Down. Right here.
• 09:53Okay.
• 09:55Do I get another five
• 09:56minutes?
• 09:57Yeah. Of course.
• 09:59I'll be very, very fast.
• 10:01I'll be super fast. So,
• 10:02anyway, so what do we
• 10:03have to do?
• 10:04Advance this? Yeah.
• 10:07That
• 10:08yep. Thank you. Okay. So
• 10:10what do we have to
• 10:10do? We have to make
• 10:11this differentiation.
• 10:12So what is the differentiation
• 10:14in our case? It's really
• 10:15an act of identifying differences
• 10:17between things between entities and
• 10:19trying to come up with
• 10:21the the sort of the
• 10:22sharpest,
• 10:23boundaries between them in order
• 10:25to tell them apart.
• 10:27It's when this principle is
• 10:29applied to psychopathology, things can
• 10:31get a little complicated.
• 10:33The premise here is that,
• 10:36psychiatric and developmental conditions,
• 10:38are really manifestations
• 10:40different kind of,
• 10:42conditions are manifestations of distinct,
• 10:45pathophysiology.
• 10:46And, our role is to
• 10:49find the boundaries
• 10:50between these entities and separate
• 10:53the groups. So separate the
• 10:54phenotypes into ideologically,
• 10:56homogeneous groups, groups that will
• 10:58also have certain clinical significance
• 11:01in terms of implications for
• 11:02prognostication
• 11:03and for treatment.
• 11:06What's interesting about this approach
• 11:08is that the boundaries are
• 11:09actually refined as our knowledge,
• 11:12expands. And you can see
• 11:13it very well here in
• 11:14the d s in the
• 11:15progression of the diagnostic statistics
• 11:17manual,
• 11:19from very early ages. You
• 11:20see that little thick little
• 11:22thin thin little thing,
• 11:24over time. So becoming more
• 11:26and more thicker,
• 11:28as more knowledge is accumulated
• 11:30and as things, as as
• 11:31the concept diagnostic concepts begin
• 11:34to evolve.
• 11:36A very good example of
• 11:37this evolution is a concept
• 11:39of autism.
• 11:41Autism has been around for
• 11:42a while, not quite a
• 11:43century yet as a diagnostic
• 11:45entity. And in nineteen forty
• 11:47three, Kenner described the first,
• 11:50set of of clinical cases,
• 11:52and he called the syndrome,
• 11:54inborn autistic disturbance of affective
• 11:57contact.
• 11:58It's a very mouthful,
• 11:59kind of thing.
• 12:02This term has been further
• 12:04refined,
• 12:05when, DSM three DSM two
• 12:07came on board in the
• 12:09nineteen seventies.
• 12:10In its label,
• 12:12autism was linked very closely
• 12:14to schizophrenia.
• 12:15It was called childhood schizophrenic
• 12:17reaction.
• 12:19DSM
• 12:20three in nineteen eighty,
• 12:22began to recognize the idea
• 12:23that autism is a very
• 12:25complex disorder. It needs to
• 12:26be a very heterogeneous disorder
• 12:29and perhaps will be better
• 12:30served if we fractionate it
• 12:33into different subtypes. In this
• 12:35case, they called it, infantile
• 12:37autism and then sub threshold
• 12:39pervasive developmental disorder.
• 12:43Nineteen ninety four, comes along,
• 12:45and Fred Bockmar,
• 12:47leads the DSM,
• 12:49for,
• 12:50task for for autism,
• 12:52and the fractionation
• 12:55further,
• 12:56develops and, Asperger
• 12:58disorder is added to the,
• 13:00to the to the fold.
• 13:03But two thousand thirteen.
• 13:06Another roundtable discussion
• 13:09results in the ideas that,
• 13:10you know, we we would
• 13:11like to fractionate,
• 13:13this heterogeneous syndrome,
• 13:15but we really, don't have
• 13:16a good good way of
• 13:17doing it. So why don't
• 13:18we just put this all
• 13:19together into a single category
• 13:21called autism spectrum,
• 13:23disorder?
• 13:26This is I can tell
• 13:27you, already, this is twenty
• 13:29three, eleven years later. I
• 13:31can tell you that this
• 13:31is not the end of
• 13:32the story.
• 13:34We are beginning to talk
• 13:35again about fractionation of the
• 13:37syndrome
• 13:37into, for instance, something that's
• 13:39called profound
• 13:41autism.
• 13:42So more to come. But
• 13:44but the idea is that
• 13:45our diagnostic
• 13:46boundaries
• 13:48evolve over time,
• 13:49and we need to be
• 13:50mindful of that evolution that
• 13:52we are part of the
• 13:53process.
• 13:54Nothing is written in stone.
• 13:56So
• 13:58when we think about young
• 13:59kids,
• 14:02there are a number of
• 14:03disorders that either can
• 14:06manifest themselves or
• 14:09may have prodromal
• 14:10characteristics
• 14:11already online,
• 14:13during the first three years
• 14:14of life. Tons of stuff.
• 14:16Autism,
• 14:18attention deficit disorder, hyper hyperactivity,
• 14:22intellectual disabilities, speech disorders, various
• 14:25speech disorders, learning disorders,
• 14:27stereotypic movement disorder, anxiety,
• 14:30conduct,
• 14:31and and probably a few
• 14:32others you can name. So
• 14:34there's a tremendously
• 14:36dense space
• 14:38very early on
• 14:40in which is these these
• 14:41symptoms can be expressed, and
• 14:43they would be expressing very
• 14:44young and immature neurodevelopmental
• 14:46systems.
• 14:49I'm going to focus today
• 14:50on on two things, on
• 14:51autism and ADHD, not because
• 14:53I know anything about ADHD,
• 14:55but I had to learn
• 14:56because Kelly would not let
• 14:58me,
• 14:59go without that.
• 15:00So, I'm going to talk
• 15:02about these two disorders because,
• 15:04they're actually,
• 15:07quite co current, and there's
• 15:08some interesting similarities and differences
• 15:10between them. And people sometimes
• 15:12wonder whether this is maybe
• 15:13the same thing,
• 15:15or maybe maybe the symptoms
• 15:17that we see of ADHD
• 15:19in autism are completely different
• 15:21story than when we see
• 15:22them in, ADHD.
• 15:24So both types the both
• 15:26disorders have very early onset,
• 15:28sometimes before the age of
• 15:29three or five.
• 15:31Very high
• 15:32prevalence, in the population. Tremendous,
• 15:34heritability,
• 15:36which suggests that genetic factors
• 15:38play a very, very important
• 15:40role.
• 15:41Unaffected family members,
• 15:44have,
• 15:45features that are related to
• 15:47the to the to the
• 15:48disorder. So they in autism,
• 15:50we have broader autism phenotype,
• 15:52and there's something,
• 15:53similar in, in ADHD.
• 15:57They are both developmental conditions.
• 15:58Symptoms change, evolve over time,
• 16:01as children grow and,
• 16:04and become,
• 16:06become more,
• 16:07capable.
• 16:09There's higher prevalence in boys.
• 16:12There's a spectrum severity. Some
• 16:14kids are very impaired. Some
• 16:15some are mildly affected.
• 16:17And each of these conditions
• 16:19have many co occurring,
• 16:22conditions as well.
• 16:26Interesting,
• 16:28stat there's a number of
• 16:29studies right now, that suggest
• 16:31that there's actually quite significant
• 16:32genetic overlap between autism and
• 16:34ADHD with about thirty, forty
• 16:36percent of genes shared between
• 16:38the two,
• 16:39disorders.
• 16:40There are studies emerging on
• 16:42brain, connectivity,
• 16:43brain structure also showing some
• 16:45similarities
• 16:46as well as differences.
• 16:48And about thirty percent of
• 16:49kids with autism will have
• 16:51ADHD,
• 16:52and many more will have
• 16:53some symptoms without meeting formal
• 16:56diagnosis
• 16:57of ADHD.
• 16:59Also, about thirty to forty
• 17:00percent of kids with ADHD
• 17:02will have some elevation of
• 17:05symptoms of autism,
• 17:07be it in a social
• 17:08or repetitive domains.
• 17:11Am I doing okay, Kelly?
• 17:15So, what do we know
• 17:16about emergence of these two,
• 17:19syndromes in early childhood? Right?
• 17:21Because if you want to
• 17:22differentiate them, we know what
• 17:24they are, what they look
• 17:25like. What is the prototype
• 17:27of autistic toddlers? What is
• 17:29the prototype of a toddler
• 17:30with ADHD?
• 17:32And only if we have
• 17:33that, we can begin to
• 17:34make,
• 17:35differentiations.
• 17:37So,
• 17:39until about twenty years ago,
• 17:40autism was not diagnosed until
• 17:42the age,
• 17:43five years,
• 17:44of age.
• 17:45And when I came to
• 17:46Yale here
• 17:47twenty five years ago or
• 17:49so, these were the discussions
• 17:50Fred and I were having
• 17:51that, you know, this is
• 17:52the state of the art.
• 17:53Anything that's happening could be
• 17:55earlier. It's really hard to
• 17:57differentiate from anything, and we
• 17:59cannot really
• 18:00we don't have right instruments
• 18:02to diagnose kids with with
• 18:04autism.
• 18:05That changed. You know? Here,
• 18:06we open in the year
• 18:08two thousand. We opened one
• 18:09of the first clinics in
• 18:10the country that focus on
• 18:12autism under the age of
• 18:13three,
• 18:15which was, which was something
• 18:16that was extremely innovative at
• 18:18that point. I'm still happy
• 18:20to say that we are
• 18:21running the same clinic.
• 18:23And,
• 18:24through our work, through work
• 18:26of our colleagues around the
• 18:28country, tremendous effort went in
• 18:30to understanding the syndrome
• 18:32in the first,
• 18:34in in in in toddler's
• 18:36second or third year of
• 18:37life.
• 18:38We found out that, yes,
• 18:40we can,
• 18:41identify
• 18:42symptoms in nonverbal and developmental
• 18:44light kids that are specific
• 18:46to autism.
• 18:47There's a whole list of
• 18:48them.
• 18:49And also,
• 18:51our colleagues,
• 18:52including Cathy Lord have developed,
• 18:55valid and reliable instruments for
• 18:57quantifying
• 18:58these symptoms in very, very
• 19:00young kids. So
• 19:02so we've made tremendous
• 19:04progress in understanding
• 19:05what a prototype of autism
• 19:07might look like in very
• 19:09early
• 19:10ages.
• 19:11And, of course, we had
• 19:12to ask the question, is
• 19:13there anything else happening,
• 19:15before that during this prodromal
• 19:17stage between birth and the
• 19:19second birthday?
• 19:20First birthday,
• 19:22complex
• 19:24conditions do not arise overnight.
• 19:26There's got to be something
• 19:28else happening
• 19:29in the brain, in the
• 19:31behavior that is forecasting
• 19:33later emergence of the syndrome.
• 19:35And, indeed,
• 19:36lots of work
• 19:38went into studying younger siblings
• 19:40of children with autism who
• 19:42have,
• 19:42elevated risk for developing,
• 19:44the disorder.
• 19:46And,
• 19:48and work here,
• 19:49in our lab, for instance,
• 19:52documented,
• 19:53that,
• 19:54way before symptoms of autism
• 19:56come online, we can see
• 19:57attentional,
• 19:59vulnerabilities in six month old
• 20:01babies more recently. We are
• 20:02looking actually at the,
• 20:04brain,
• 20:05structure and connectivity in neonates
• 20:07in relation to later outcomes
• 20:09in these siblings.
• 20:11So,
• 20:12lots of work, happening in
• 20:14that space,
• 20:15and, and it's definitely more
• 20:17to come.
• 20:18In that context,
• 20:20if I can make a
• 20:21quick plug, we are just
• 20:22starting a new,
• 20:24study that's focused on brain
• 20:26imaging
• 20:27in newborns.
• 20:28So if you're pregnant, if
• 20:29you're thinking of getting pregnant,
• 20:31if you know someone who's
• 20:32pregnant, or if you know
• 20:33someone who's pregnant who has
• 20:34a family member of a
• 20:36child with autism, do let
• 20:37us know.
• 20:39We'll be delighted delighted to
• 20:41say hello to them.
• 20:43So what's happening,
• 20:45in ADHD? Again, we're looking
• 20:47for a prototype. What do
• 20:48we know about ADHD in
• 20:49young kids? Same stories with
• 20:51autism.
• 20:52Not typically diagnosed until the
• 20:54age of five. People started
• 20:56asking questions what's happening before
• 20:59for good reasons,
• 21:00including the fact that the
• 21:02parents were telling everyone.
• 21:04My child always was like
• 21:06that. Why are we talking
• 21:07about
• 21:08the diagnosis now?
• 21:10So,
• 21:11there has been some research
• 21:13in that space, but certainly
• 21:14not as much as we
• 21:16did as as it happened
• 21:17in autism.
• 21:19There has been some research
• 21:20on fine tuning diagnostic criteria
• 21:23so they can be extended
• 21:24to kids who are younger
• 21:26by excluding some of the
• 21:28verbal items. So that was
• 21:29great.
• 21:30And research in this space
• 21:32is actually quite spare. It's
• 21:34it's largely focused on temperamental
• 21:36indices
• 21:37where researchers ask parents to
• 21:39rate their children along multiple
• 21:41dimensions
• 21:42and, children, the
• 21:44tend to have,
• 21:46surprisingly, or maybe not high
• 21:48activity level, elevated
• 21:50propensity to respond with negative
• 21:52affect to, challenges, environmental
• 21:55challenges,
• 21:56and difficulty sustaining
• 21:58attention.
• 21:59And they also may may
• 22:00show some elevated,
• 22:03social and repetitive behaviors,
• 22:05that are typically associated with
• 22:07autism.
• 22:09But,
• 22:10we know much less about
• 22:12them, as we, know about
• 22:14toddlers with autism. And when
• 22:15we think about potential prodrome,
• 22:17we are not even calling
• 22:18it necessarily a prodrome yet
• 22:20in ADHD.
• 22:21There is not much work.
• 22:22There's some work on on,
• 22:25babies who later were diagnosed
• 22:27with autism, and and they
• 22:29also this research also suggests
• 22:30that there are some temperamental
• 22:32markers
• 22:33temperamental features,
• 22:35that are seen in kids
• 22:36who develop autism, but these
• 22:38are not diagnostic markers. None
• 22:40of these are specific to
• 22:41autism.
• 22:42ADHD, they are seen in
• 22:44other kids.
• 22:45So,
• 22:48very, very limited.
• 22:50I wish, you know, if
• 22:51this was my wish, if
• 22:52I could do anything, if
• 22:53I had the same money
• 22:54as, Bezos,
• 22:55I would invest it really
• 22:57into trying to understand the
• 22:59early program of, a lot
• 23:01of the new developmental conditions,
• 23:04because this is the time
• 23:05and space,
• 23:06for doing that,
• 23:08but we are not quite
• 23:09there yet. So what are
• 23:10the clinical implications?
• 23:11So I I'm eternally grateful
• 23:13to Kelly, Mariana, and Chelsea
• 23:15for helping with this table,
• 23:17which basically summarizes,
• 23:19clinical,
• 23:22wisdom
• 23:23of, you know, what happens
• 23:24when you get into the
• 23:25room with with a toddler.
• 23:26The toddler's climbing the walls,
• 23:28not really responding to name,
• 23:30not really looking necessarily
• 23:32in in the eyes,
• 23:33and not playing so well
• 23:35that you could say, okay.
• 23:37They they are finding that
• 23:38domain.
• 23:39So how do you how
• 23:40do you separate? How do
• 23:42you make a differentiation whether
• 23:43on a no. These difficulties
• 23:45are due to
• 23:46social disability
• 23:48or attentional
• 23:49challenges.
• 23:51I could spend an hour
• 23:52talking about this table, but
• 23:54I can only I can
• 23:55plug some of these things.
• 23:57So for instance,
• 23:59young kids, preschoolers with autism,
• 24:02ADHD have
• 24:03often elevated scores
• 24:05on screeners for autism.
• 24:08It could be an AMCHAT,
• 24:10SRS,
• 24:11maybe even an ADOS based
• 24:13on the work we do
• 24:14in our in our clinic.
• 24:16So, in the context of
• 24:18face to face interaction, they
• 24:20might not make eye contact.
• 24:21They may have
• 24:23a problem with they might
• 24:24be a little grabby. They
• 24:25might be getting in your
• 24:26space. They might be not
• 24:27looking at you and so
• 24:29forth. And and what we
• 24:30found the most important is
• 24:32to consider context
• 24:33and manipulate the,
• 24:36environmental
• 24:37variables
• 24:38to see whether we can
• 24:39enhance the child's engagement
• 24:42by, limiting number of distractions
• 24:44by scaffolding in in in
• 24:46some ways.
• 24:48And if we can do
• 24:49that, we can say safely,
• 24:51okay. This child is not
• 24:52really making a lot of
• 24:53eye contact, but,
• 24:55because he's so distracted
• 24:56by everything. He's he needs
• 24:58to grab everything at the
• 24:59same time and,
• 25:00climb the walls.
• 25:02So, his social engagement is
• 25:03a little,
• 25:04law on a lower side.
• 25:08Same goes with with language.
• 25:09We see language delay across
• 25:11developmental conditions.
• 25:13Again, what's important for us
• 25:15is ability to communicate without
• 25:17words in autism is profoundly
• 25:19affected
• 25:20and,
• 25:21and,
• 25:24scaffolding it in a context
• 25:26of social interaction
• 25:27hardly ever makes it better,
• 25:29where it whereas it makes
• 25:30it much better for kids
• 25:31with ADHD or other conditions.
• 25:35Kids, with ADHD
• 25:36often also show,
• 25:39repetitive behaviors,
• 25:41motor therapy, sensory interests, which
• 25:44are often seen in autism,
• 25:46and and that often makes
• 25:48people think, oh, wow. This
• 25:49kid must have ate, autism.
• 25:52But, first of all,
• 25:55therapy or or more or,
• 25:57repetitive behaviors are not specific
• 25:59to autism.
• 26:00They're also present in multiple
• 26:02conditions. So in and of
• 26:03themselves, they are not good
• 26:05diagnostic
• 26:06indicator.
• 26:09So, all of this is
• 26:10not,
• 26:11is not really,
• 26:13a a matter of academic
• 26:14discussion because,
• 26:16children who have, dual diagnosis,
• 26:19autism and ADHD,
• 26:21typically do much worse than
• 26:22children who only have autism.
• 26:24And that's true of school
• 26:26age children and also true
• 26:28of children,
• 26:29who are much younger, who
• 26:30are preschoolers.
• 26:32And for that reason, we
• 26:33need to try to include
• 26:35screenings for screening for ADHD,
• 26:38for, even very young kids,
• 26:41in order to identify potential
• 26:43risk factors, which are going
• 26:44to actually
• 26:45affect their outcomes in a
• 26:47very, very significant way.
• 26:51So,
• 26:54given the complexity of our
• 26:56tasks in clinics on a
• 26:58on a daily basis,
• 26:59we need to consider several
• 27:01things.
• 27:02Whatever we do, however we
• 27:04differ try to differentiate
• 27:05what we see is going
• 27:07to depend tremendously
• 27:08on the quality of information
• 27:10that's available to us.
• 27:12And yet,
• 27:14across the world,
• 27:15we are facing tremendous pressure
• 27:18to simplify diagnostic processes, to
• 27:21do less, to do more
• 27:22with less,
• 27:24to,
• 27:25use screening instruments instead of,
• 27:29instead of more,
• 27:30direct,
• 27:31assessment methods, and use less
• 27:34experienced clinicians to in to
• 27:36interpret this data, make decisions
• 27:38about diagnosis,
• 27:40and, prescribe treatment.
• 27:44Given the complexity
• 27:45of of the of the
• 27:47of the landscape and psychopathology
• 27:49they are face faced with,
• 27:51I would like to argue
• 27:52that we need to stick
• 27:54to the old school,
• 27:56for now
• 27:57until we develop better measures
• 27:59or biological markers.
• 28:01Stick to the old school,
• 28:03assessments where we actually employ,
• 28:05clinicians who are highly,
• 28:07highly trained
• 28:09and are capable of assessing
• 28:12functioning across multiple areas of
• 28:14functioning. This this is the
• 28:15only way we can actually
• 28:16prescribe
• 28:17treatment. Treatment will depend
• 28:19on the child's individual profile
• 28:22of strength and weaknesses, and
• 28:23I feel like I'm channeling
• 28:25Sarah Sparrow here.
• 28:26Right, Lori?
• 28:29Amen.
• 28:32Also a pervasive presence of
• 28:34of co co occurring conditions
• 28:35truly,
• 28:37calls for, paying attention to
• 28:39other dimensions that that we
• 28:40don't,
• 28:41typically, and and screen also
• 28:43for emotional problems, attentional, and
• 28:45regulatory functions.
• 28:49Keeping
• 28:50while we do all of
• 28:51this, while we do all
• 28:52this important work,
• 28:54in in our clinics, we
• 28:56also,
• 28:57give ourselves a bit of
• 28:58a break
• 28:59and, and remember that this
• 29:01uncertainty that we expect experience,
• 29:05is real.
• 29:06It's real for several reasons.
• 29:07One is that the diagnostic
• 29:08boundaries we are operating
• 29:10with
• 29:11are,
• 29:12are changing.
• 29:13Right? They're evolving. It's an
• 29:15evolving science. They are still
• 29:16under development.
• 29:18And we need to remember
• 29:19that.
• 29:20These are
• 29:21not platonic
• 29:23forms, Plato's forms,
• 29:24that that we are referring
• 29:26to.
• 29:28Also,
• 29:31sometimes the source of uncertainty
• 29:33is
• 29:34the changes
• 29:35in the presentation
• 29:36over time in very young
• 29:38kids.
• 29:41And that's something to be
• 29:42expected
• 29:43because we are trying to
• 29:45nail down or pinpoint some
• 29:47kind of
• 29:48constellation of features in the
• 29:50system, your developmental system that's
• 29:52rapidly changing,
• 29:54right, in terms of brain
• 29:56connectivity,
• 29:57brain structure, brain
• 29:59you know, how behavior, environment
• 30:01shapes shapes these important,
• 30:03determinants
• 30:04of outcomes.
• 30:06And, also, we are changing
• 30:08the kids.
• 30:09You know, when a child
• 30:10comes to to to the
• 30:11clinic
• 30:12and we prescribe treatment and
• 30:14we see them again and
• 30:15they're fabulous,
• 30:17we probably changed the kid.
• 30:19It's not that we've made
• 30:20a mistake the first time
• 30:21around.
• 30:23You know, there's a very
• 30:24interesting example from the studies
• 30:26of baby siblings of children
• 30:28with autism. We have a
• 30:29consortium that's sort of,
• 30:31in in the US or
• 30:32actually international consortium.
• 30:34And we look at the
• 30:35babies across time,
• 30:38several thousands of them. Right?
• 30:40It's stunning because
• 30:42once the child
• 30:44is detected once we detect
• 30:45that the child has difficulties,
• 30:47twelve months, fourteen months, sixteen
• 30:48months, we prescribe treatment.
• 30:50And then when we look
• 30:51at this group,
• 30:53thousands of babies,
• 30:54they are so doing so
• 30:56much better than general population
• 30:58of kids with autism. So
• 30:59much better.
• 31:01We're changing reality. There's
• 31:03there's also possible that there
• 31:04are some protective factors that
• 31:05are kicking in. And another
• 31:07example is, girls with autism.
• 31:09When we see them when
• 31:10they're very young, we see
• 31:11quite a few girls who
• 31:13have, you know, prototypical
• 31:14presentation
• 31:15in a toddler
• 31:16of autism. But
• 31:18there is a there's a
• 31:19significant group of girls who
• 31:21actually do better over time
• 31:22than boys.
• 31:24As if, you know, the
• 31:25protective some protective factors were
• 31:27kicking in or compensatory factors
• 31:29were kicking kicking in, and
• 31:31their trajectories
• 31:32are going to diverge from
• 31:33those that we see in
• 31:34voice.
• 31:36When in doubt, always,
• 31:37fall back on provisional diagnosis.
• 31:40We use
• 31:41what do we like? We
• 31:42like,
• 31:43un specifying your developmental condition,
• 31:46treat symptoms, reevaluate,
• 31:47and,
• 31:48most importantly, support family
• 31:51throughout the process.
• 31:53Your uncertainty should not be.
• 31:55There are uncertainty.
• 31:57Okay. So, how much time
• 31:59do I have?
• 32:01Twenty five minutes.
• 32:02Oh my god.
• 32:05Okay. So I really zoomed
• 32:07through it. Alright. So,
• 32:10alright. So this is great.
• 32:11Fantastic. So I can slow
• 32:13it down.
• 32:15So
• 32:16what are the alternatives?
• 32:18Right?
• 32:20What are the alternatives?
• 32:21I told you about, methods
• 32:23that
• 32:24are capitalized on differences.
• 32:26Right?
• 32:28Defining boundaries, capitalizing on differences,
• 32:31comparing groups, and hoping for
• 32:33the largest separation of of
• 32:35distributions,
• 32:37in terms of diagnosis.
• 32:39So another approach is to
• 32:42focus on similarities.
• 32:44Right? We already talk about
• 32:45the fact that,
• 32:47there are similarities
• 32:49in in,
• 32:51same symptoms might be present
• 32:52across multiple conditions.
• 32:55Right?
• 32:56And so,
• 32:57we can focus on that
• 32:58and try to understand what
• 32:59is that about.
• 33:01Right?
• 33:02I mean, there there's there's
• 33:03several assumptions,
• 33:05associated with this approach.
• 33:08First, that symptoms are distributed
• 33:10on a continuum,
• 33:11and there are some
• 33:14some symptoms like social engagement,
• 33:16social motivation,
• 33:19selective attention,
• 33:21variability, nonverbality
• 33:23is distributed on a continuum
• 33:24with with some very low
• 33:26scores and very high scores,
• 33:28something in the middle.
• 33:29And different disorders might be
• 33:31falling onto different kind of,
• 33:34place in this in this
• 33:35in this continuum.
• 33:37And there's also an assumption
• 33:38in this approach that the
• 33:39symptoms,
• 33:41seen across different conditions are
• 33:43driven by the same psychopathology.
• 33:45Now these two points may
• 33:47seem very simple,
• 33:48and straightforward, but they are
• 33:50not. They're extremely complicated, and
• 33:52there's a lot of work
• 33:53going on to try to
• 33:54figure out
• 33:55which symptom dimensions actually fall
• 33:57under these these these categories.
• 33:59So if we were to,
• 34:00for instance, think about
• 34:03can you see that? Yep.
• 34:04I can see that. So
• 34:05if you if if you
• 34:06can print for instance, think
• 34:08about two dimensions. Right? You
• 34:09know, social engagement and repetitive
• 34:11behaviors, and this is a
• 34:13zero. You can imagine that
• 34:14if we take several disorders,
• 34:17if you take autism, ADHD,
• 34:19intellectual disability,
• 34:20individuals
• 34:21from different,
• 34:23different individuals might fall into
• 34:25different,
• 34:26parts of this distribution.
• 34:27Right? And this is the
• 34:29simplest,
• 34:30two dimensional,
• 34:31representation
• 34:32of these of these,
• 34:34possible,
• 34:35dimensions.
• 34:36But, in reality, we're probably
• 34:38looking at many, many, many
• 34:40more.
• 34:41Now this trust diagnostic and
• 34:43dimensional approach is mostly right
• 34:45now used in research.
• 34:47It has not I don't
• 34:48think unless unless I miss
• 34:50something, has not trickled down
• 34:52yet to clinical,
• 34:54practice or clinical applications.
• 34:57Just to give you some
• 34:58like, an example of of,
• 34:59you know, how this work
• 35:01can be done, how it's
• 35:02done, how it might inform
• 35:03clinical practice
• 35:05is, I'll I'll I'll walk
• 35:07you through,
• 35:08some of the,
• 35:10recommendations
• 35:11or frameworks, research frameworks that
• 35:13were advanced by the National
• 35:15Institutes of Mental Health.
• 35:19They identify
• 35:20several important
• 35:22domains
• 35:23of, psychopathology.
• 35:25And within each domain, there's
• 35:26specific dimensions.
• 35:29So, you know, negative positive
• 35:31valence, cognitive systems, social processing,
• 35:35and so forth. And within
• 35:36each of them, are there
• 35:38specific
• 35:40groups or dimensions or of
• 35:41symptoms that can be considered
• 35:43or important in psychopathology?
• 35:46One of these,
• 35:47one of these domains is
• 35:49a sensory
• 35:50motor domain, and sensory motor
• 35:51domain
• 35:52includes, many different things that
• 35:54has to do with with
• 35:55motor planning, habits,
• 35:59and so forth. But it
• 36:00also includes something that we
• 36:01call a repetitive movements or
• 36:04motors stereotypies. And I'm going
• 36:05to talk about this for
• 36:06a moment
• 36:07just to give you, this
• 36:09kind of work as an
• 36:10example of what what we
• 36:11can do and maybe where
• 36:12we're gonna go with our
• 36:13field.
• 36:14So,
• 36:15complex motor stereotypies,
• 36:18involve,
• 36:19repetitive,
• 36:20habitual
• 36:21movements of of fingers, hands,
• 36:25other body parts.
• 36:27They're,
• 36:29they need to be distinguished
• 36:30from so called simple motor
• 36:32therapies that could be nail
• 36:33biting or
• 36:35or,
• 36:37similar things that we see
• 36:38in in very young or
• 36:39thumb sucking or related,
• 36:43related behaviors.
• 36:45Motor steatibis are present,
• 36:47in autism, and they're also
• 36:49present in other, conditions.
• 36:51They are distributed in a
• 36:53spectrum of severity.
• 36:55Some are so severe that
• 36:57they cause,
• 36:58injury,
• 36:59self injury, and some of
• 37:01them are completely benign,
• 37:03present, but completely,
• 37:05benign.
• 37:06There's an ongoing
• 37:07discussion in the field whether,
• 37:09these,
• 37:11repetitive movements are purposeless
• 37:14or whether we call them
• 37:15purposeless only because we don't
• 37:16understand their function.
• 37:18And,
• 37:20their function
• 37:21in theory could involve many
• 37:23many very helpful things
• 37:25like regulation of arousal,
• 37:28and,
• 37:29reactivity.
• 37:30And we don't know much
• 37:31about the underlying
• 37:33etiology, but we know it's
• 37:34it's a biological phenomenon.
• 37:36There's some genetic markers for
• 37:38for for stereotypies.
• 37:41So, give you a couple
• 37:42of examples. This is this
• 37:44is a beautiful little girl
• 37:45who,
• 37:46came to us through our
• 37:48complex motor therapies
• 37:50complex
• 37:53complex neurodevelopmental
• 37:54condition program. Sorry about that.
• 37:57And she came to us
• 37:59when she was about twelve
• 38:00months old. This is her
• 38:01six at six months.
• 38:04And she started doing these
• 38:05little things
• 38:08and,
• 38:10moving her feet
• 38:12when they're excited.
• 38:15She's clearly not perturbed.
• 38:18If anything, she's happy.
• 38:20But it worried the parents.
• 38:22This was her a little
• 38:23bit
• 38:25later when she could sit
• 38:26on her own
• 38:29when she came to see
• 38:30us, and this was her
• 38:34Do you wanna go sit
• 38:35at the table too? So
• 38:36motor stereotypies here involve
• 38:38hands and, happy feet, happy
• 38:40hands,
• 38:41movements, also adding some, composition
• 38:44of of, face grimacing,
• 38:47of of posturing.
• 38:49This child does not have,
• 38:52any neurological
• 38:53condition other than than motor
• 38:55motor stereotypy.
• 38:56No no epilepsy.
• 39:00So,
• 39:01we wanted to understand,
• 39:03this phenomenon a little better,
• 39:04and we've been working with
• 39:05with Tom and his group.
• 39:08Tom has truly pioneered the
• 39:09research on motor stereotypical here
• 39:11at the child study center.
• 39:12We started talking
• 39:14what might what might this
• 39:15look like in toddlers.
• 39:17Not too many people actually
• 39:18look at this phenomenon in
• 39:19toddlers.
• 39:20So we wanted to ask
• 39:21the question,
• 39:22what are toddlers like,
• 39:24and what is the underlying
• 39:25potentially biology?
• 39:27So we took we leveraged
• 39:29findings from over seven hundred
• 39:30toddlers who came through our
• 39:32clinics,
• 39:33and we, were able to
• 39:34evaluate their motorist their tippies
• 39:36based on direct
• 39:37assessment.
• 39:39And, the first thing that
• 39:40we we found was quite
• 39:42interesting was that the prevalence
• 39:43is is actually,
• 39:45distribution is kind of interesting.
• 39:47Sixty percent,
• 39:49of kids with autism had
• 39:51mother's third tip is so
• 39:52not everyone.
• 39:53Right? Thirty percent of kids
• 39:55without autism, with other conditions,
• 39:57had motor stereotypies, and about
• 39:59ten percent
• 40:00of kids without anything
• 40:02also showed some stereotype behaviors.
• 40:05So that was interesting.
• 40:08What we also did, we
• 40:09we controlling for the diagnostic
• 40:12grouping. We also look for
• 40:13association
• 40:15between presence
• 40:16of motor stereotypies
• 40:18and,
• 40:19developmental
• 40:20outcomes both concurrently and prospectively.
• 40:23And it was also very
• 40:25interesting because the presence of
• 40:26motor stereotyping was associated with
• 40:29a low lower cognitive skills,
• 40:31a low lower language skills,
• 40:33less social skills.
• 40:35And it was true,
• 40:38both concurrently and also prospectively,
• 40:41which suggested something something very
• 40:44interesting,
• 40:45to us that that
• 40:47seeing a child with moderate
• 40:48stereotyping may signal
• 40:50that we actually should be
• 40:52paying attention even though the
• 40:53child may just have simple
• 40:55motor stereotyping. We need to
• 40:56actually pay attention to
• 40:58what is else is happening
• 41:00in their development.
• 41:02Now a lot of,
• 41:03effort went into discussion. What
• 41:05is the relationship between mother
• 41:06stereotypies and and, let's say,
• 41:08cognition
• 41:09or, language or social functioning?
• 41:13And some people propose that
• 41:14mother stereotypies actually cause them.
• 41:16There's a causal relationship. They
• 41:18prevent the child from engaging
• 41:20into something that's more adaptive
• 41:22and so forth. We see
• 41:23absolutely no evidence for that.
• 41:26If anything,
• 41:27we think that what is
• 41:29really happening is that the
• 41:30neural circuitry
• 41:32that's responsible
• 41:33or involved in producing,
• 41:35motor cell TPC is also
• 41:37involved in controlling
• 41:40cognition,
• 41:40attention, executive
• 41:42function, and language.
• 41:44So multiple functions
• 41:46are subserved
• 41:47by the same
• 41:49by the same complex and,
• 41:52subcortical to cortical circuitry.
• 41:55And
• 41:56perhaps any kind of alteration
• 41:58within this when the within
• 41:59this network can produce a
• 42:01broad spectrum
• 42:03of developmental,
• 42:05outcomes, including,
• 42:06motors.
• 42:08So,
• 42:09so this is really the
• 42:10first paper of this kind
• 42:12in in toddlers, but we
• 42:13we we try to recommend
• 42:15that,
• 42:16a presence of,
• 42:18moderate stereotypies should really, trigger
• 42:20monitoring, developmental monitoring.
• 42:22And, if there are,
• 42:25if there are any persistent
• 42:27patterns of delays, also intervention
• 42:29focus not on motor stereotypies,
• 42:31but on the delays that
• 42:32we see in other domains.
• 42:34Intervening on stereotypies, it's a
• 42:36whole different thing because
• 42:38a motor stereotypies typically are
• 42:40not unless they are lead
• 42:42to self injury,
• 42:43they're actually not,
• 42:45impinging upon the child's,
• 42:48happiness or well-being or or,
• 42:51they're not distressing.
• 42:53So,
• 42:54unless they are distressing, we
• 42:55need to be very, very
• 42:56careful and very judicial in,
• 42:59considering,
• 43:00treatment.
• 43:01And in in that consideration,
• 43:03we need to take,
• 43:04really, really seriously,
• 43:07we need to understand very
• 43:08seriously,
• 43:09the function
• 43:10and the, and and what
• 43:12what really is the family
• 43:14take on it or the
• 43:15child's take on what's happening
• 43:16with their own body.
• 43:18So it's not an automatic
• 43:20target for treatment.
• 43:22So,
• 43:23with things like stereotypies, which
• 43:25we think might be a
• 43:26dimension that cuts across multiple,
• 43:29disorders,
• 43:30maybe driven by the same,
• 43:32mechanisms. We we don't know
• 43:33yet. We are collecting some
• 43:35genetic data,
• 43:36on on our cohort. We
• 43:38might know a little bit
• 43:39more,
• 43:40later.
• 43:42Tom's earlier work has shown
• 43:43that there are some overlaps
• 43:45between,
• 43:46risk genes for autism and
• 43:47complex motor
• 43:49therapies,
• 43:50in children without autism.
• 43:52So lots to come. This
• 43:54is really definitely a space
• 43:56that that requires a lot
• 43:57of attention.
• 43:58But before we even go
• 44:00to underlying biology, we have
• 44:01to measure them using the
• 44:02same instruments.
• 44:04Everyone measures them differently.
• 44:06It's really, really hard to
• 44:08put together,
• 44:09some sensible conclusions from studies
• 44:12where where the phenomenon is
• 44:13measured,
• 44:14by parent report, by a
• 44:16checklist of of two items,
• 44:18by observe
• 44:19observation
• 44:20and so forth.
• 44:25What's also very important is
• 44:26for us to, we owe
• 44:28it to our families and
• 44:29to the kids to understand
• 44:31their functional significance
• 44:32because that's a highly neglected
• 44:34area, right now, and and
• 44:36we are trying to get
• 44:37into that space as well.
• 44:39And and be very, very
• 44:40careful in terms of interventions.
• 44:45So
• 44:49with that, I would like
• 44:50to thank you. I would
• 44:51like to thank thank you
• 44:52for your attention and
• 44:54acknowledge,
• 44:55all the families to come
• 44:57through our,
• 44:58studies and our funding agencies.
• 45:00Amazing, amazing team,
• 45:03in my lab and the
• 45:04clinic.
• 45:06And,
• 45:06thank you very much for
• 45:08your attention.
• 45:16Well, thank you very much,
• 45:17Kasia, especially for giving the
• 45:19talk. Everybody's on an incredibly
• 45:21warm room. This is
• 45:24I'm I'm surprised that no
• 45:25one's falling asleep.
• 45:27Well, it's I've seen some
• 45:28ice closed.
• 45:32Questions for doctor Habashkin.
• 45:37Thank you. Thank you, Kasia.
• 45:39I have a comparative
• 45:40question. So as you know,
• 45:41I'm a primatologist
• 45:43and in
• 45:44monkey
• 45:45literature, at least with monkeys
• 45:47that exhibit self injurious behavior,
• 45:49there have been studies showing
• 45:51that they direct their biting
• 45:53to acupressure points and that
• 45:54lowers heart rate. So that
• 45:56supports the arousal reduction.
• 45:58I'm not aware of any
• 46:00research into stereotypies, but monkeys
• 46:02do exhibit stereotypical behaviors as
• 46:04well. And I'm just wondering,
• 46:05is there any work that's
• 46:07starting to examine this arousal
• 46:09reduction hypothesis
• 46:10in children?
• 46:12This is absolutely fascinating.
• 46:14I I did not know
• 46:15about that. Well, we,
• 46:18there's very, very few studies
• 46:20which try to evaluate Matthew
• 46:22Goodwin comes to mind from
• 46:23Northwestern who tried to monitor
• 46:26arousal throughout the day
• 46:28in people with autism who
• 46:29are,
• 46:31moving around and doing their
• 46:32going be, about their lives
• 46:34and try to,
• 46:36identify some patterns in in
• 46:38arousal changes, whether there's some
• 46:39kind of rise be right
• 46:40before,
• 46:41what's happened after the the
• 46:43start of the. It's really,
• 46:45really hard. Yeah. There was
• 46:46there was one study from
• 46:47our colleagues from Netherlands in
• 46:49the
• 46:50nineties, I would say. Really
• 46:52good study. Maybe ten patients.
• 46:55Matthew did maybe similar number
• 46:58of so not not really.
• 47:00There's not much. We're we
• 47:01are recording,
• 47:04skin conductance
• 47:05throughout their visits when they
• 47:06come to our clinic.
• 47:09It's a better analyze
• 47:10data if anyone is interested.
• 47:15Yes. A lot of work
• 47:16needs to happen.
• 47:28K. K. K.
• 47:29Thank you so much. I
• 47:30am wondering if you put
• 47:32on an ethics hat
• 47:34and
• 47:35talk about,
• 47:36to whom it's impairing
• 47:39these stereotype behaviors and what
• 47:41movement we've made
• 47:43societally
• 47:45to,
• 47:46be more accepting
• 47:48of these behaviors that
• 47:50are not impairing,
• 47:52to the child.
• 47:54They might be socially
• 47:56stigmatizing, but they're not impairing.
• 47:57And so there's a real
• 47:58ethical dilemma about targets
• 48:01of treatment.
• 48:02And maybe you could tell
• 48:03us what's happening in the
• 48:04autism world about
• 48:07taking an ethics lens
• 48:09to targets of behavior.
• 48:11This is an excellent question.
• 48:13It's about, is it ethical
• 48:14to to intervene if the
• 48:16symptoms are not
• 48:17interfering with the child's well-being?
• 48:20And this is exactly the
• 48:21argument that has been raised
• 48:22by the autism advocates
• 48:24who,
• 48:26who
• 48:27bring up the issue. You
• 48:28know, these behaviors help me.
• 48:30When I walk into,
• 48:32this, you know, very busy
• 48:33environment and I engage in
• 48:36something that's comforting,
• 48:38it helps me stay in
• 48:39that environment.
• 48:40So they they point clearly
• 48:43to functional significance of these
• 48:45behaviors.
• 48:46I think in science, we
• 48:47are behind that because we've
• 48:49taken the the the perspective
• 48:51of looking from the outside
• 48:52in
• 48:53and saying, you know, this
• 48:55looks weird.
• 48:56And and can we can
• 48:57we normalize it? Right?
• 49:00And and I think, thankfully,
• 49:01the field is moving from
• 49:03from from from this approach.
• 49:05And it applies to children
• 49:06with autism, but it also
• 49:07applies to children with with,
• 49:09motorist
• 49:10who have no no other,
• 49:13cognitive or or language or
• 49:14other difficulties
• 49:16and who will display these
• 49:17behaviors. And we are seeing
• 49:18them. We are seeing them
• 49:20in in our through our
• 49:22program.
• 49:23Some of them, especially when
• 49:24we see them as older
• 49:25kids, Kelly, you can say
• 49:27something more about that.
• 49:29They they they developed their
• 49:30own way of saying about
• 49:31it. So, you know, I
• 49:32I was born like that.
• 49:33Like, we ask, you
• 49:35know, how does it feel?
• 49:36You know? What what do
• 49:37you think about it? You
• 49:38know? How do you,
• 49:40like, negotiate
• 49:41your life in the in
• 49:42the classroom?
• 49:43Room? And she's they would
• 49:45say just, you know, I
• 49:46was born like that.
• 49:48And,
• 49:49and kind of try to
• 49:50send send their ground,
• 49:52you know, governing.
• 49:55So so,
• 49:57I I think
• 49:58as a society, we have
• 50:00a lot to do
• 50:02to be able to accept
• 50:03people for who they are
• 50:05if they are different because
• 50:06we really don't
• 50:08our our our tolerance for
• 50:10otherness
• 50:12is extremely limited,
• 50:14and we see it across
• 50:17multiple phenomena, not just psychopathology.
• 50:20And and we need to
• 50:21create space where
• 50:23people can be who they
• 50:24are.
• 50:34Thank you so much.
• 50:37Now transitioning to putting on
• 50:39a clinical hat,
• 50:41I am wondering
• 50:42I have a lot of
• 50:43parents that I've been working
• 50:44with over this year that
• 50:46will say,
• 50:47we have a picture of
• 50:48ADHD
• 50:49and
• 50:50some
• 50:51autistic like traits,
• 50:53and parents will say, well,
• 50:55is it autism or is
• 50:56it not? What does it
• 50:57mean? What are these extra
• 50:59stereotypical behaviors or what what
• 51:01do the extra things mean?
• 51:03I'm wondering what you might
• 51:05be
• 51:06able to say or what
• 51:08would you say to the
• 51:09parents in that situation, and
• 51:11what could be helpful for
• 51:12us as clinicians to be
• 51:14able to educate them about?
• 51:17You know, it's it's a
• 51:18very important question. We want
• 51:20certainty.
• 51:22We really don't like uncertainty.
• 51:24We don't we don't like
• 51:25to be sort of, one
• 51:27foot here, one foot there.
• 51:31From you know, everyone is
• 51:33different. Right? So so with
• 51:34different families, you you take
• 51:36a different approach.
• 51:37What's important for us is
• 51:39that when we see families
• 51:40for diagnostic evaluation and and
• 51:42we know there are complex
• 51:43questions ahead,
• 51:46Every moment we spend with
• 51:47them, it's a it's a
• 51:48psychoeducational
• 51:49moment.
• 51:50Right? We discuss, you know,
• 51:52what are your concerns? What
• 51:53do you think it it
• 51:53might be? Right? And, you
• 51:55know, tell me about your
• 51:56family. Tell me about,
• 51:59who else in the family
• 52:00may have x, y, and
• 52:01z. Right? And and sort
• 52:03of try to open them
• 52:04up to the
• 52:06to the various possibilities
• 52:07and the fact that, development
• 52:09is a beautiful thing. It's
• 52:11a nonlinear.
• 52:12And and we often use
• 52:13that argument with with families,
• 52:15which is a great thing
• 52:17because that means possibilities are
• 52:18endless.
• 52:28Tasha,
• 52:34thank you so much for
• 52:35a great presentation.
• 52:37Since you spoke about,
• 52:40ADHD
• 52:41versus autism,
• 52:42can you comment a little
• 52:44bit about, any updates on
• 52:46the theory of mind research
• 52:48and how ADHD and autism
• 52:50might be different with regard
• 52:52to this theory of mind,
• 52:54field?
• 52:57That's an excellent question.
• 53:00I am I am more
• 53:02focused on low kids
• 53:04than
• 53:06older kids, and I have
• 53:08less of an understanding
• 53:10of the theory of mind
• 53:11differentiation.
• 53:14In the nineties,
• 53:17and the odds, there was
• 53:18a strong emphasis on the
• 53:20theory of mind impairment in
• 53:22in autism.
• 53:24It's the the picture is
• 53:26probably not as straightforward
• 53:28as we thought it was,
• 53:30back then.
• 53:31So, I'm not up to
• 53:33speed on this literature in
• 53:34terms of more sophisticated
• 53:38levels of differentiation.
• 53:42Maybe someone else is in
• 53:43the audience.
• 53:49Well, I think the message
• 53:50of resisting the urge to
• 53:52other people is a wonderful
• 53:53message
• 53:54to end the twenty twenty
• 53:55four grand round series on.
• 53:57So if there are no
• 53:58further questions for doctor Vashka,
• 54:00I'd like to,
• 54:01thank you very much for
• 54:02a wonderful presentation.